LymeForward Health and Wellbeing Group Proposals for improvement in provision of local health, care and support services January 2018 Life is really simple, but we insist on making it complicated. Confucius Any intelligent fool can make things more complex. It takes a touch of genius and a lot of courage to move in the opposite direction. Ernst Schumacher Quite clever people make simple things complex; very clever people make complicated things simple. Richard Anderson, Health and Social Care Community Services Manager, East Devon LymeForward CIC is a Community Interest Company No 10381732 Financially supported by Lyme Regis Town Council and West Dorset District Council LymeForward: Gaps, weaknesses and concerns regarding local health, care and support services. January 2 Page!1
The current re-commissioning of the Virgin Care contract has given the opportunity to review the ways in which health and care services are provided locally. These notes indicate, in broad terms, how we would wish that provision to be developed. We would refer the CCG also to our paper dated 20th June 2017, which provided an early assessment of needs and offered initial proposals. Some of our recommendations fall outside the CCG's remit; we hope that other commissioning authorities and providers will also take this opportunity to review how services are arranged in the Lyme Regis and Charmouth area. Details underlying these suggestions are contained in LymeForward's complementary document highlighting concerns about current provision. We hope that the matters included there will be carefully considered during the re-commissioning process so that the aims of the Sustainability & Transformation Plan to achieve equal standards of care, and improved access with more services closer to home can be realised. We recognise that all services are these days under acute financial pressure. Proposals 1, 3, 4, 5, 6, 8, 9, 12 & 15 that follow all imply cost savings in, at least, the medium- to long-term. LymeForward Reference Document: Provision of local health, care and support services. v.1 January 2018 Page 1! 2
1. Dorset HealthCare (DHUFT) to manage Community Services Integrating community services into the arrangements for the rest of the county would strengthen the professional staff and provide more reliably for local residents. It would simplify the currently complex overlaps between Virgin and DHUFT provision and management, and probably reduce overall management and administrative costs. The multi-disciplinary team at the Bridport Hub inspires confidence, so a service more closely integrated with that team would be beneficial. 2. Establish a well-staffed and managed 'sub-hub' in Lyme Regis The potential risk in proposal (1) above is that the magnetic attraction of the populous east of the county could be reflected in too strong a pull away from LymeRegis and Charmouth towards Bridport, whereas a theme of our analysis (and of the STP) is the need for more services to be delivered closer to home. It would be essential, therefore, so to commission this integration that Lyme Regis has a clearlydefined base for patient access: a distinct sub-hub closely connected to Bridport but with its own dedicated staff, based on those currently serving and at least at the present level with enhancements in key areas. The sub-hub should have sufficient autonomy and flexibility in staffing and funding to be able to adapt its services to local needs. It would need strong leadership with a clear overview of all services available to local people, whether directly commissioned by the CCG and provided by DHUFT, or outside that framework. The resources of modern information technology could be harnessed to maintain full connection with the central hub while working 'remotely'. 3. Better resource the primary mental health care for children and adolescents The current under-provision of care for young people with mental health issues builds up serious human and financial costs. Providing more, and more professionally-appropriate, care should be a priority and an investment that will prove a cost-saving in the longer term. Noting that 2.0wte (adult) mental health nursing posts are currently vacant in the Virgin community services, and that a review is currently under way, perhaps the opportunity for some reallocation of resources from adults to children could be considered? 4. Better resource the community nursing services A strengthened team for community nursing, occupational therapy and physiotherapy would enable stronger services for hospital at home, intermediate care and night-sitting. That would begin to tackle the current flaws in hospital discharge arrangements, to recognise the high level of frailty in the local elderly population, and to fill the gaps in palliative care. It would contribute significantly to the (national) aim of keeping people out of hospital and care homes wherever possible, and of facilitating the earliest possible discharge from hospital. It would bring immediate human benefits and longer-term cost savings to the NHS. 5. Strengthen, simplify and better coordinate services for children and families Recognising that this matter concerns other bodies beside the CCG, we nonetheless regard it as critical and urgent. Service fragmentation is bad for clients, and puts extra demands on staff. We recommend a careful review of how these services are provided in order to stop the steady draining away of provision from Lyme Regis and Charmouth, the risk to Children's Centre facilities, and the growing number of family and parenting challenges. Again, serious improvement and simplification in these services would be an investment, reducing eventual human and financial cost. 6. Review and strengthen adult social services and social care With the imminent retirement of the local social worker, we recommend that the opportunity is taken to review that provision. A lone social worker is insufficient to cover all the demands across this area, given the high level of need for social care, support and advice. The difficulty for people in accessing home care when so little is available locally must be addressed. Consideration should be given to increasing the number of NHS-funded 'step-down' beds locally, and the 'bed-blocking' evident with those already notionally available must be resolved. LymeForward: Proposals for improvement in provision of local health, care and support services January 2018 Page! 1
7. Bring forward practical solutions to improve access and transport In this locality, the CCG's stated aim of improving access to services faces particular challenges. In principle, the barriers to access can be overcome in either or both of only two ways: to commission specific transport services, or to focus on bringing services to people rather than moving people to services. Accepting that levels of specialist skill and equipment will always place limits on such an aim, we believe the latter approach to be the more practicable solution. It would require smart organisation, some sophisticated use of IT systems, and possibly a culture-shift for some professionals: it would be worth the effort. 8. Resolve cross-border barriers Access challenges could also be eased by eliminating the range of barriers to seamless health and care across the county boundaries barriers that make no sense in what is called a 'National' Health Service. Closer integration with, for example, the services of the Axe Valley health and care hub, with Axminster Hospital, and with Devon Social Services would reduce patient travel difficulties and cut down on the time-consuming extra administrative work for staff dealing with multiple agencies. Linked care records and IT systems, with standardised protocols and procedures, are essential. 9. Build closer links between professional services and 3rd Sector / voluntary support A reasonable number of support services, whether provided by other agencies, 3rd sector bodies or volunteers, already exist in the immediate area: a resource that can help to take the strain off professionals and prevent costly deterioration of patient conditions. It is a policy of LymeForward to do what it can to increase the number of such groups functioning in the vicinity so as to minimise travel barriers that arise when the location is Bridport or even further. Evidence suggests that the need is often greater than the take-up, in some cases risking sustainability. This mismatch appears to be in part attributable to insufficiently active signposting and referring by professionals. A requirement for all professional staff to know in detail what support services are available, and actively to encourage participation, should be built into any new specification of services. 10. Better define the Minor Injuries Unit / Out of hours provision The status of the Minor Injuries Unit, currently staffed by nurses from the GP Practice at LRMC but available to the whole community and beyond, must be resolved. To be fully effective, it needs greater scope in the conditions it can handle, so that it can fill the gap between the end of normal GP Practice nursing hours and the start of the 111 Out-of-Hours service. It existence and services must also be promoted more effectively, particularly during the busy holiday season when demand is greatest. 11. Restore full Fire Service engagement in the First Responder service Public confidence was high in the Fire Service team that previously handled all First Response requirements. The more recent introduction of other Responders alongside the Fire Service team has not proved satisfactory, so a return to the simpler status quo ante is recommended. 12. The model of GP / medical service provision The proposal for 'a single GP Provider' in this area is one that we do not fully understand, nor do we see quite in what form that might be achieved. But the following observations would apply under the circumstances of any new model: - Charmouth must retain the GP services it currently enjoys; - a significantly stronger emphasis on health promotion, early intervention and preventative medicine should be required; - GPs should be more actively engaged in managing or supervising arrangements for patients' hospital discharge, improving communication with hospitals and other agencies involved; - if necessary in association with the sub-hub, GP surgeries should maximise the number of routine tests, screening, diagnostics, pre-operative checks, out-patient clinics and day case interventions available locally, to minimise patient exposure to travel barriers; LymeForward: Proposals for improvement in provision of local health, care and support services January 2018 Page! 2
- GP appointment waiting times must be reduced at LRMC, along with increased GP staff stability and improved continuity of care; - if rationalisation of the scheme for GP/medical provision can bring economy in administrative costs as well as greater professional coordination, that would be welcome. But it must not be achieved at the cost of patient access to known GPs and nurses, nor at the cost of patient confidence. 13. Improve public communication As well as improved communication within and between professional teams, we would hope that core services are required to meet specified standards in their communications with the public. For example, in the case of GP Practices, it would be desirable to have: - a single Practice brochure, regularly updated; - a single Practice website, maintained up-to-date; - the websites and brochures carrying identical information about the sub-hub, community services, other key agencies and local voluntary groups across the area of the three Practices; - language suitable for lay people, avoiding medical jargon. The three Practices and the sub-hub should make regular use of newsletters, local print media, electronic communications, and social media to communicate news and to promote healthy living. 14. Strengthen local accountability and quality assurance In the spirit of the NHS Constitution, health and care services should recognise accountability to the population they serve as well as to higher authorities something that, as an exercise in partnership, would strengthen public confidence in and support for those services. It will be helpful to specify mechanisms whereby local people can provide 'on the ground' feedback. These might involve clearer definition of the role of the three PPGs, and establishing ways whereby LymeForward's Health & Wellbeing group, in association with the PPGs, could be a recognised partner of the various Quality and Scrutiny bodies. Making publicly available the explicit specifications against which service contracts are awarded, so that local people understand what is expected in terms of the level of service and the access they provide, would be an essential underpinning of such partnerships. 15. Establish a single, Locality-based, integrated health and care system Our researches have indicated weaknesses and dysfunction in the current local health and care arrangements that could be eased or eliminated through simplification and local delegation. A pilot project, furthering the national ambition of integrating health and social care while tackling the particular challenges of a lightly-populated rural area, would be worthwhile. Its elements might include: - a single Locality as a defined operating area for all services, rather than the present variations in definition across different services: the current CCG-defined Locality would be that used for a Health and Wellbeing Board, as a Social Services area, as the West Family Partnership Zone, etc.; - a single budget, delegated from the CCG, NHS England, Public Health Dorset, Dorset Adult Social Services, Dorset Children's Services, etc.; - a single management system, with flexibility to deploy human and material resources across the full range of services in a way that best meets local needs; - a single oversight Board to eliminate the range of often-overlapping bodies that currently exist, inefficient in function and wasteful of time and money. Such a framework could over time ensure, in the most cost-effective manner, genuinelyintegrated working across services and teams, responsiveness to changing demands, strong professional sharing and mentoring, clarity of pathways for local people, and reduced calls on professionals' time for servicing bureaucracy and meetings. It should bring stability to a system that at present is too prone to frequent changes. An arrangement of this sort would be likely to make more feasible seamless liaison with contiguous and similar systems in East Devon and South Somerset, since it would not involve the full county-wide apparatus. LymeForward: Proposals for improvement in provision of local health, care and support services January 2018 Page! 3